MEDICARE: MCKENZIE BRACE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	8342	MN
2	163WC3500X	Cardiac Rehabilitation Registered Nurse	2375351	MN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2375351	OTHER	MN	RN

General Provider Information

NPI Number	:	1508416579
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MCKENZIE BRACE

Provider Business Mailing Address
First Line	:	3243 FILLMORE ST NE
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55418-2152
Country	:	US
Telephone Number	:	319-939-8354
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 INGLEWOOD AVE S
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4112
Country	:	US
Telephone Number	:	914-589-5503
Fax Number	:	763-465-0588

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/12/2019
Last Update Date	:	08/03/2021

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Directions to “ MCKENZIE BRACE ” Practice Location

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